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Last Words

clock November 25, 2012 06:34 by author Lisa Bonsall, MSN, RN, CRNP

I’ve seen a lot of patients die. And by a lot, I mean too many to count. Some deaths I remember clearly, perhaps because the patient was alone or had a large number of family and friends at the bedside, perhaps because he or she was close to my age, or perhaps because of religious traditions that took place during or after the death. It’s odd then, that when I think back to last words of patients before they died, I am at a loss. 

It could be because many of our patients followed a similar pattern prior to their death. Many were on mechanical ventilation which was withdrawn after many days, weeks, or months of progresses and setbacks. Most were unresponsive, either due to sedation or their disease process. They may have spoken their last words in my presence, but at the time I may not have realized that they were the last words they would ever speak. 

I do remember the last words of one patient in our unit. She was my grandmother. After a fall with a resultant hip fracture, she was transferred to us several weeks after surgical repair of her hip. Her oxygen requirements were increasing and she was becoming more and more agitated. In our unit she was treated for aspiration pneumonia, given anxiolytics, and supported with more and more supplemental oxygen each day.

We, her family, knew her wishes – she didn’t want to be intubated – and we respected that. I was working night shift, not as her nurse, but would stay much of the morning to help with her am care and to be there for rounds. On one particular morning, she was coughing and vomited. She had a hard time catching her breath. I called out for her nurse to suction her, when my grandmother grabbed my hand and said “No more.” We spoke of what that meant; it was a pretty intense conversation for a young nurse to have with her own grandmother. Then I called the rest of the family to explain our conversation and ask that they come to be with us. 

Everyone arrived throughout the day and we did what we could to keep her comfortable. We all spent time holding her hand and chatting with her when she was able. At one point, my grandmother asked for a grape soda. I found one for her and as she sipped it through a straw, she said to me “Lisa, I won’t be at your wedding.” “I know,” I said, “Grandmom, but you will always be with me.” Her response was “Yes… and grandpop knows what to give you.”

And those were her last words to me. I knew that she was referring to a wedding gift, and I laugh now when I think about it, because that was typical of my grandmother. She was an incredibly generous woman…always fighting over the check at dinner and pushing to pay at any cash register. These final words make me smile and think of who she was, not laying on that hospital bed, but as my grandmother.

What made me think of this was a recent book I just completed. In Looking for Alaska by John Green, the main character has a fascination with last words. He reads countless biographies and has memorized last words, even making it his mission to discover the “Great Perhaps” mentioned in the last words of François Rabelais. It was a good read, definitely thought-provoking, and I thank my niece for recommending it to me.

As nurses, some of us work with dying patients on a daily basis, while others, only rarely or sometimes. Regardless of your experience, do any last words stand out in your memory?



Clinical Symposium on Advances in Skin & Wound Care 2012

clock October 24, 2012 15:17 by author Lisa Bonsall, MSN, RN, CRNP

As I write this, I’m on my flight home from the Clinical Symposium on Advances in Skin & Wound Care 2012 which was held at Caesars Palace in Las Vegas, Nevada. Thank you to the conference chairpersons, Sharon Baranoski, MSN, RN, CWCN, APN, DAPWCA, FAAN and Richard Salcido, MD. It was an informative, well-organized, and fun conference!

I was particularly drawn to the sessions which addressed skin care and pressure ulcer management at the end of life. Even in the keynote address, Legally Defensible Wound Care, presented by Caroline E. Fife, MD, CWS and Kevin W. Yankowsky, JD, this was a theme. An interactive case presentation was the format and we, the audience, got to share our opinions/votes by holding up a red or green card to questions such as “Was this pressure ulcer a result of negligence?”, “Would you take the case?”, and “Should the hospital be sued?”, among many others. During the presentation, an interesting observation was shared. When a cause of death is identified as ‘heart failure’ or ‘renal failure,’ a response of sympathy often results; however, a cause of death of ‘skin failure’ often leads to more negative responses, such as “that never should have happened” or even a search for somewhere or someone on which to place blame. 

The lesson that I learned, both from this keynote address and from a session titled Skin & Wound Care at Life’s End: Clinical Considerations, presented by Sharon Baranoski, MSN, RN, CWCN, APN, DAPWCA, FAAN, is that the skin is an organ and at the end of life, it will fail just as the heart and kidneys and other organs do. Despite optimal care and evidence-based interventions for skin and wound care, skin failure and pressure ulcers often are unavoidable at the end of life. 

Here are some more highlights from the conference:

  • Book signing! Sharon Baranoski, MSN, RN, CWCN, APN, DAPWCA, FAAN and Elizabeth Ayello, PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN were on hand to sign their book Wound Care Essentials, Third Edition. 
  • Exhibit Hall! The exhibitors shared their products in dynamic ways, including wound care karaoke & dressing change races.
  • Quotes! Looking back on my notes, I just have to share these wise words that were shared.
    • “The keys to preventive legal care and effective communication are managing expectations beforehand and answering questions afterward.” Kevin W. Yankowsky, JD
    • “Edema is the real enemy.” Sandra Wainwright, MD (discussing chronic venous hypertension ulcers)
    • “Anytime cartilage is present, you have a stage IV pressure ulcer.” Diane K. Langemo, PhD, RN, FAAN
    • “If there is stable eschar on a heel, leave it alone!” Diane K. Langemo, PhD, RN, FAAN
    • “We all own pressure ulcers, not just nurses.” Elizabeth Ayello, PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN
    • “The Braden scale accounts for most risk factors for pressure ulcers, but we also need to think about perfusion, age, comorbidities, and if the patient has a history of pressure ulcers.” Dr. Janet Cuddigan

You can see some pictures from the conference on our Facebook page. Next year, this conference will be held in Orlando, FL on October 24-27, 2013. It would be great to see you there!



Communication and relationships

clock May 23, 2012 03:24 by author Lisa Bonsall, MSN, RN, CRNP

Each week we select 3 articles to feature on our Recommended Reading list. We rotate the items on this list so there are always 10 articles available – and they are all free to read! It’s fun for me to choose these articles for several reasons – first, I get to do a lot of reading, but most of all, because I do think about what I’m “hearing” here on our blog, out there on our social media pages, and in real-life discussions with my nursing friends, when I select the articles to include each week. We also select 3 continuing education articles to include on our Recommended CE list, and remember, all of our CE articles can be read online free!

A hot topic lately, and one that is dear to me, is communication. Interactions with both patients and our colleagues are so important for outcomes and patient and staff satisfaction. We know that patients trust us, we know that we know our patients well, and we know that we are important members of the healthcare team. One of our current featured articles, Facilitating Goals-of-Care Discussions for Patients With Life-Limiting Disease—Communication Strategies for Nurses, has a great section with the heading Nurses' Special Relationship With Patients: 

“For those with a life-limiting illness, nurses are the "constant" in their journey through a frequently fragmented healthcare system. The nurse becomes familiar with the patient's medical history, health status changes, "behind the scenes" discussions of the team, family dynamics, and expressions of thoughts, concerns, and values. Thoughtful communication is essential throughout the trajectory. As the nurse builds a relationship based on trust and consistency, he/she may be viewed as "more approachable" than others in the healthcare team and, as a consequence, be part of informal discussions with patients and families. Therefore, the nurse is well positioned to facilitate discussions focused on goals of care and treatment choices in the setting of a progressive debilitating illness.”

We do have special relationships with our patients. They are relationships that allow us into patients' lives during critical times, they are relationships that allow us to advocate for our patients, and they are relationships that allow us to provide the best possible nursing care to our patients. I hope you enjoy this article and the others on our Recommended Reading lists! 

Happy Reading Laughing

Reference

Peereboom, K., & Coyle, N. (2012). Facilitating Goals-of-Care Discussions for Patients With Life-Limiting Disease—Communication Strategies for Nurses. Journal of Hospice and Palliative Nursing, 14(4). 



Yes, Nurses do Make a Difference

clock May 6, 2012 01:59 by author Lisa Bonsall, MSN, RN, CRNP

Every year Nurses Week rolls around and nurses are told “thank you” by their institutions; if you are lucky, you may receive a token of appreciation like a lunch bag, a water bottle, or a beach towel. The research is clear, nurses do make a difference in patient outcomes and nurses are the most trusted profession according to the Gallop poll. This is my 28th year experiencing Nurses Week, but this year I am seeing it a little differently.  

My mother passed away last year on May 25th from small cell lung cancer. From the day she was diagnosed to the day she died was 2 and a half months. She tried chemo but it didn’t work, it often doesn’t. She never regretted trying the chemo because it gave her the time to say good bye to all of her family and friends. Her friends were incredibly supportive of her and the rest of our family. You see, her friends were all nurses. They helped prepare meals, assist with her activities of daily living, and administer her medications. They even stayed overnight when one of the family couldn’t stay. They allowed me to be the “daughter” not always the caregiver. When my mom died, she was surrounded by her children and three of her best friends who were all nurses. These women made all the difference in the world to my mom and our family. They made it possible to keep her where she wanted to be – at home. 

Being a nurse doesn’t end when you retire or take time off to raise your family. It is an innate part of who you are and how you conduct yourself each and every day. So, during this Nurses Week, if you come upon a nurse who is retired or is taking some time off, say “thank you…you make a difference.”

Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse
Wolters Kluwer Health / Lippincott Williams & Wilkins / Ovid Technologies  



EOL Care: Progress and Ongoing Issues

clock February 11, 2012 15:45 by author Lisa Bonsall, MSN, RN, CRNP

End-of-life (EOL) care has always been a special interest of mine. I know the frustrations that often arise with EOL care in a critical care unit – for example, when a patient can no longer make decisions for himself and his family is unsure of his wishes, or when family members disagree. However, I also know how satisfying it can be when a patient’s death is a positive experience for all involved. Sometimes providing end-of-life care is just as rewarding as seeing a patient ‘turn the corner’ and get better. I imagine that some nurses find that EOL care is even more rewarding. 

When I read Ethics in Critical Care: Twenty Years Since Cruzan and the Patient Self-Determination Act: Opportunities for Improving Care at the End of Life in Critical Care Settings, I was reminded that while challenges continue, we actually have come pretty far with regards to advance care planning (ACP) and EOL care. Resources such as the Center for Practical Bioethics’ Caring Conversations, Respecting Your Choices, and Five Wishes have emerged to help patients and families discuss their wishes with one another. Other highlights of progress include The Joint Commission standards on palliative care, advance care planning, and pain management; National Healthcare Decisions Day (April 16); palliative care consultation services at large numbers of hospitals; and increased numbers of people with advanced directives. I encourage you to read this article in its entirety to see the extensive list of examples provided by the authors. 

What issues remain? 

  • Advance care planning – increasing the number of patients with advance directives; living wills & power of attorney issues
  • Caring for patients who are in a minimally conscious state vs. persistent vegetative state
  • Providing hydration and nutrition
  • Communicating a patient's wishes or plan of care during transfer from one care setting to another (for example, from nursing home to hospital)

Take some time to read this article (it’s free to read online while on our Recommended Reading list!). On page 103 (page 5 of the pdf), you’ll find 'Ten Things Critical Care Nurses Can Do To Improve Advance Care Planning.' 

Reference: 

Rushton, C., Kaylor, B., & Christopher, M. (2012). Ethics in Critical Care:Twenty Years Since Cruzan and the Patient Self-Determination Act: Opportunities for Improving Care at the End of Life in Critical Care Settings. AACN Advanced Critical Care, 23(1). 



Support your fellow nurse

clock January 26, 2012 04:53 by author Lisa Bonsall, MSN, RN, CRNP

We see, read, and hear so much about horizontal violence and nurses not being supportive of each other, and also about other healthcare professionals being unsupportive of nurses. Another such case is occurring, but what is striking to me, is that while this one nurse is going through this tough time, nurses on the web are rallying together to support her and encouraging others to do the same.

The case is of Amanda Trujillo, a registered nurse in Arizona. According to a letter she wrote and the posts of many nurse bloggers, Amanda has been fired from her job, her nursing license is in question, and she is undergoing psychiatric evaluation after educating a patient about his illness and options. The patient decided to forgo surgical intervention and explore hospice care. The details of her case can be read on a number of nursing blogs, including vdutton’s posterous (with the transcript of details recorded by her attorney), Those Emergency Blues, and Emergiblog. The Nerdy Nurse also has several posts and an extensive list of resources about the case and ways to show support.

I can think of several instances where patients I’ve cared for had questions that either were not answered by the healthcare team or were answered, but the patient did not fully understand his condition or options. On many  occasions in my nursing career, I provided patient education that helped a family make an  informed decision. I’ve called together family meetings with the healthcare team and requested ethics committee consultations. Advocating and educating patients, within the scope of nursing practice and institution policies, of course, is our responsibility. 

I will be following the case to see what evolves and the response of nursing organizations. Thank you to the nurses who have been sharing Amanda’s story.



A Special Thank You

clock November 23, 2011 02:27 by author Lisa Bonsall, MSN, RN, CRNP

When I started to think about a special post to write for Thanksgiving, I tried to remember a time when I really grew as a nurse. There was no question in my mind about a certain patient that was instrumental in that growth. The crazy thing was I never even knew her.

It started out like any other shift – I was assigned two patients (we were fully staffed), a wonderful leader and my former preceptor was our charge nurse for the evening, and a team of interns and residents who had been in our Medical Intensive Care Unit for a few weeks were working. All the beds were full and none of our patients were up for transfer out of the unit, so it seemed like we were in for a calm shift.

Linda was a young woman who had a uterine rupture during childbirth and had lost a lot of blood. She subsequently developed acute respiratory distress syndrome (ARDS) and had come to our unit about 2 weeks prior to this particular evening for intubation and management of her ARDS. She had no significant past medical history, no known allergies, and had an uncomplicated pregnancy with regular prenatal care.

During change-of-shift report, I learned from the day shift nurse that the MICU team had met with Linda’s family that day after a neurological exam and testing had revealed that Linda was brain dead. The family had decided to gather together this evening and we’d remove Linda from the ventilator. They had also requested to donate her organs.

A representative from Gift of Life arrived shortly after the start of my shift and the family started to drift in as well. Never had I been part of such an emotional patient experience. The strength and courage of the family of this young woman – this new mother – was incredible. While their grief was palpable in the room, so was their faith. They verbalized gratitude at being fortunate enough to be able to donate several of Linda’s organs and saw this as a way to continue her life.

So, this special thank you goes out to Linda and her family…

Thank you for allowing me to be part of that night.

Thank you for sharing your faith with me.

Thank you for sharing your stories with me.

Thank you for teaching me that death, even a tragic one, can give us strength that we might not even know is within us.  

Thank you for thinking of others and giving life. 



Decisions, decisions

clock April 14, 2011 10:02 by author Lisa Bonsall, MSN, RN, CRNP

Living wills. Life support. Do-Not-Resuscitate. These are all phrases that I used frequently working in an adult medical intensive care unit. I rarely had trouble using the words death, dying, hospice, or end-of-life with patients and families.

However, outside of the hospital, these words have been a lot harder for me. My parents do have living wills and have expressed their wishes to me, but not because I initiated any discussion with them. In fact, I’ve actually avoided those conversations despite knowing how important they are. 

There is not really a good time to have end-of-life discussions, so people tend to wait for the "right time" which often turns into the "wrong time" or "too late." The conversation might end up taking place in the hallway of the emergency department or in a critical care waiting room. Sometimes, information is conveyed and decisions are even made over the phone.

I am fortunate that my own family members have insisted on preparing for the end of their lives and sharing their plans and wishes with me. As a daughter, I really don’t like to hear about it. As a nurse, I know that this is a very good thing.

Saturday, April 16th is National Healthcare Decisions Day. Make this day the "right time" to talk with your loved ones and encourage the patients you care for to do the same.



More to think about at the end of life

clock July 11, 2010 19:19 by author Lisa Bonsall, MSN, RN, CRNP

Providing end-of-life care can be one of the most challenging responsibilities as a nurse, yet can also be one of the most fulfilling. When a patient’s wishes are respected and dying with dignity is a priority, death can be a peaceful and positive experience for the patient, his family, and the staff caring for him.

Oftentimes, our focus during end-of-life care is primarily on pain management and relieving or preventing labored breathing. Research published last month in the Archives of Internal Medicine calls attention to other factors that need to be addressed to improve care at the end of life. These include communication deficits, the importance of dyspnea assessments, implantable cardioverter/defibrillator deactivation, and bowel regimens.

In my opinion, the importance of communication at the end of life cannot be stressed enough. This includes communication among staff, among the patient and his family members, and between staff and the patient and his family. How many times have you encountered family members who didn’t agree with the wishes of a loved one as stated in his living will or who didn’t understand that an illness was terminal? How about physicians, nurses, and other professionals who were reluctant to address end-of-life issues?

It is important for all decision-makers and caregivers to understand and agree on a plan in order to ensure a positive experience at the end of life. For this to happen, communication is key. Take some time to read the following articles. You’ll find some great information to help educate patients, families, yourself, and your colleagues about end-of-life issues and care.



Making decisions about end-of-life care

clock March 1, 2010 03:44 by author Lisa Bonsall, MSN, RN, CRNP

An article about end-of-life care received front page billing in The Philadelphia Inquirer this past Sunday. The article A look at the new field of palliative care describes the case of a previously active 74-year old woman who became seriously ill. When a meeting was set up with the palliative care team, family members expressed concerns about “death panels” and “pulling the plug.” They did not anticipate that the goals of this first family meeting were to talk about managing their loved one’s pain, answer questions, and provide information to help them make decisions about her care.

The article goes on to describe the role and goals of a palliative care team. With quotes from both the team members and the patient’s family members, this well-written article really serves to educate the public about making end-of-life decisions. It shows us that making decisions about care are not always a matter of live or die, but more an ongoing process about providing appropriate care.  The article also discusses the importance of living wills and having discussions with one’s family before critical illness occurs. 

As a former critical care nurse, I know how satisfying it was when we had what we called a “save” – when a patient near-death turned the corner and got better. I also know how satisfying it was for a patient to have a “good death.” At that time we didn’t have a palliative care team, but we did have plenty of family meetings.  Helping a patient and family have a positive experience and make the right decisions for their family member was an important part of my job. Is there a palliative care team where you work? How are you involved in discussions about end-of-life care?



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